Healthcare Provider Details

I. General information

NPI: 1639391998
Provider Name (Legal Business Name): MICAH N PRYOR LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 WOODELL
CLINTON AR
72031
US

IV. Provider business mailing address

2535 DONAGHEY AVE #3532
CONWAY AR
72032
US

V. Phone/Fax

Practice location:
  • Phone: 501-745-8433
  • Fax: 501-745-8453
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberA0401003
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: